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  1. 1. OSHAcademy Course 702 Study GuideEffective AccidentInvestigation
  2. 2. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 2 of 71OSHAcademy Course 702 Study GuideEffective Accident InvestigationCopyright © 2013 Geigle Safety Group, Inc. No portion of this text may be reprinted for other than personaluse. Any commercial use of this document is strictly forbidden.Contact OSHAcademy to arrange for use as a training document.This study guide is designed to be reviewed off-line as a tool for preparation to successfully completeOSHAcademyCourse 702.Read each module, answer the quiz questions, and submit the quiz questions online through the coursewebpage. You can print the post-quiz response screen which will contain the correct answers to thequestions.The final exam will consist of questions developed from the course content and module quizzes.We hope you enjoy the course and if you have any questions, feel free to email or call:OSHAcademy1915 NW Amberglen Parkway, Suite 400Beaverton, Oregon 97006www.oshatrain.orginstructor@oshatrain.org+1.888.668.9079
  3. 3. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 3 of 71ContentsModule 1: The Basics.............................................................................................................................................7What is an accident?.........................................................................................................................................7Accidents and incidents ....................................................................................................................................7Accident Types ..................................................................................................................................................7Are accidents always unplanned?.....................................................................................................................8Old Theory - Worker Error ................................................................................................................................9New Theory - Systems Approach ......................................................................................................................9Why conduct an "investigation"?......................................................................................................................9Characteristics of an effective accident investigation program .....................................................................11Module 1 Quiz.................................................................................................................................................13Module 2: Initiating the Investigation.................................................................................................................15Why conduct the investigation? .....................................................................................................................15Lets get started! .............................................................................................................................................15When should you secure the accident scene? ...............................................................................................15Why secure the accident scene?.....................................................................................................................16Two things may disappear after an accident occurs.......................................................................................16Reporting accidents to OSHA..........................................................................................................................17What information do I need to give to OSHA about the incident? .............................................................17Module 2 Quiz.................................................................................................................................................19Module 3: Documenting the Accident Scene .....................................................................................................21Document before it goes away.......................................................................................................................21Why the team approach works best...............................................................................................................21Methods to document the accident scene.....................................................................................................21Make personal observations.......................................................................................................................22Get initial statements..................................................................................................................................22
  4. 4. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 4 of 71Take photos of the accident scene .............................................................................................................22Take video clips of the scene ......................................................................................................................23Sketch the accident scene...........................................................................................................................23Some sketching pointers.............................................................................................................................24Interview records ........................................................................................................................................26Final words… ...................................................................................................................................................26Module 3 Quiz.................................................................................................................................................27Module 4: Conducting Effective Interviews........................................................................................................29Digging up the facts can be a challenge..........................................................................................................29Steves Seven "Rights" of the interview process.............................................................................................29Cooperation is the Key!...................................................................................................................................29Preparing for the interview.............................................................................................................................30Effective Interviewing Techniques..................................................................................................................31Final words... ...................................................................................................................................................32Module 4 Quiz ................................................................................................................................................33Module 5: Conducting Event Analysis.................................................................................................................35Introduction.....................................................................................................................................................35Sorting it all out...............................................................................................................................................35Analysis defined ..............................................................................................................................................35Why accidents happen....................................................................................................................................36Single Event Theory.........................................................................................................................................36The Domino Theory.........................................................................................................................................36Multiple Cause Theory ....................................................................................................................................37The final event in an unplanned process ........................................................................................................37Four categories of events................................................................................................................................37
  5. 5. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 5 of 71Developing the sequence of events................................................................................................................39The two components of an event: The Actor and the Action.........................................................................39Sample sequence of events.............................................................................................................................40Paint a word picture........................................................................................................................................41Sample sequence of events.............................................................................................................................41Make sure you are constructing only one event ............................................................................................42Final words... ...................................................................................................................................................42Module 5 Quiz.................................................................................................................................................43Module 6: Determining the Causes ....................................................................................................................45Introduction.....................................................................................................................................................45The harmful transfer of energy is the direct cause of injury ..........................................................................45The surface causes of accidents......................................................................................................................46Hazardous conditions..................................................................................................................................46Unsafe or inappropriate behaviors.................................................................................................................46Below are some examples of unsafe or inappropriate employee/manager behaviors.............................47The root causes of accidents...........................................................................................................................47Three levels of cause analysis .........................................................................................................................48Injury Analysis .................................................................................................................................................49Harmful forms of energy.................................................................................................................................49Event Analysis..................................................................................................................................................50More on Event Analysis...................................................................................................................................51Final words… ...................................................................................................................................................52Module 6 Quiz.................................................................................................................................................53Module 7: Developing Solutions.........................................................................................................................55What is a good recommendation?..................................................................................................................55
  6. 6. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 6 of 71Why decision-makers dont respond quickly..................................................................................................55Do it right! .......................................................................................................................................................55The Hierarchy of Control Strategies................................................................................................................56Higher priority strategies that control hazards...........................................................................................56Lower priority strategies to control exposure and behaviors ....................................................................57Recommend system improvements ...............................................................................................................58"GIGO" or "QIQO"?..........................................................................................................................................59To develop great recommendations, ask six key questions ...........................................................................59Estimating direct and indirect costs................................................................................................................62What is the ratio between direct (insured) and indirect (uninsured) costs in your scenario?...................62What is the ratio between total accident costs to direct costs? ................................................................63What is return on the investment (ROI)?....................................................................................................63Provide options ...............................................................................................................................................64Module 7 Quiz.................................................................................................................................................65Module 8: Writing the Report.............................................................................................................................67Introduction.....................................................................................................................................................67Perception is reality.........................................................................................................................................67The Accident Report Form ..............................................................................................................................67Section I. Background..................................................................................................................................68Section II. Description of the accident ........................................................................................................68Section III. Findings......................................................................................................................................68Section IV. Recommendations ....................................................................................................................69Section V. Summary ....................................................................................................................................69Open Document..............................................................................................................................................69Module 8 Quiz.................................................................................................................................................70
  7. 7. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 7 of 71Module 1: The BasicsWhat is an accident?An accident is the final event in an unplanned process that results in injury or illness to an employee andpossibly property damage. It is the final effect of multiple causes.An "event," occurs when one "actor" (one person/thing) performs an "action" (does something). In thisdefinition, a person or thing will do something that results in a change of state. Accidents are processes thatculminate in a final event that causes injury or illness. An accident may be the result of many factors(simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.Accidents and incidentsAccidents are part of a broad group of events that adversely affect the completion of a task. These events areincidents. For simplicity, the procedures discussed in this course apply most appropriately to accidents, butthey are also applicable to all incidents in general. Think of it this way: accidents cause injuries and incidentsdo not.Accident TypesAn accident isnt just an event that you can lump into one big category. In reality, there are many differenttypes of accidents. Lets take a look at a partial list.-Struck-by. A person is forcefully struck by an object. The force of contact is provided by the object.-Struck-against. A person forcefully strikes an object. The person provides the force or energy.-Contact-by. Contact by a substance or material that, by its very nature, is harmful and causes injury.-Contact-with. A person comes in contact with a harmful substance or material. The person initiates thecontact.-Caught-on. A person or part of his/her clothing or equipment is caught on an object that is either moving orstationary. This may cause the person to lose his/her balance and fall, be pulled into a machine, or suffersome other harm.
  8. 8. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 8 of 71-Caught-in. A person or part of him/her is trapped, or otherwise caught in an opening or enclosure.-Caught-between. A person is crushed, pinched or otherwise caught between a moving and a stationaryobject, or between two moving objects.-Fall-To-surface. A person slips or trips and falls to the surface he/she is standing or walking on.-Fall-To-below. A person slips or trips and falls to a level below the one he/she was walking or standing on.-Over-exertion. A person over-extends or strains himself/herself while performing work.-Bodily reaction. Caused solely from stress imposed by free movement of the body or assumption of astrained or unnatural body position. A leading source of injury.-Over-exposure. Over a period of time, a person is exposed to harmful energy (noise, heat), lack of energy(cold), or substances (toxic chemicals/atmospheres).Are accidents always unplanned?We like to think that accidents are unexpected or unplanned events, but sometimes, thats not necessarilyso. Some accidents result from hazardous conditions and unsafe behaviors that have been ignored ortolerated for weeks, months, or even years. In such cases, its not a question of "if" the accident is going tohappen: Its only a matter of "when." But unfortunately, the decision is made to take the risk.A competent person can examine workplace conditions, behaviors and underlying systems to predict closelywhat kind of accidents will occur in the workplace. Technically, we cant say an accident is always unplanned.Like any system, a safety management system is designed perfectly to produce what it produces.Consequently, written safety plans may be (unintentionally) designed such that they create circumstancesthat cause accidents.In companies that decide to take the risk, its likely their attitude about accidents is that, "accidents justhappen; theres nothing we can do about them." Of course, thats an unacceptable notion in any effectivesafety culture. Employers with a healthful attitude about accidents consider them to be "inexcusable," anddemand that hazards be corrected before they cause an accident.
  9. 9. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 9 of 71Old Theory - Worker ErrorOld thinking about the causes of accidents assumes that the worker makes a choice to work in an unsafemanner.It implies that there are no outside forces acting upon the worker influencing his actions and that there aresimple reasons for the accident. Old thinking also considers accidents as solely resulting from worker error: Alack of "common sense." Actually, common sense is an invalid concept. No one has common sense. Rather,we each develop a unique and hopefully "good sense" based on individual experience, education, etc.Assuming common sense also allows management to more easily place blame for accidents squarely on theshoulders of the employee. The employee is "the problem." So, to prevent accidents, the employee mustwork more safely. This thinking results in blaming and short-term fixes that are inefficient, ineffective, and inthe long run more expensive to implement and maintain.New Theory - Systems ApproachThe systems approach takes into account the dynamics of systems that interact within the overall safetyprogram. It concludes that accidents are considered defects in the system. People are only one part of acomplex system composed of many complicated processes (more than werealize). Accidents are the result of multiple causes or defects in the system.It becomes the investigators job to uncover the root causes (defects) in thesystem. Fixing the system, not the blame, is the heart of the investigation. Toprevent accidents, the system must work more safely. This line of thinkingresults in long-term fixes that are actually less expensive to implement andmaintain.Why conduct an "investigation"?The answer to this question is key to the success of the entire program. Does your organization conductaccident investigations for the same reason as OSHA? To determine the purpose of a process, its importantto look at the "output" of that process. The fatality investigation report is the output of the investigationprocess, so lets take a look at the sample given in OSHA Instruction CPL 2.113, Appendix C:
  10. 10. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 10 of 71MEMORANDUM FOR: Regional AdministratorFROM: Area DirectorSUBJECT: Notification of Results of FatalityInvestigationThe following information supplements the OSHA-170, regarding investigation of the accident at _____Company, Inc., which occurred on June 15, 1995.Establishment Information: ____Company, Inc., located at Grainfield Road, Grossfield, USA, has no previousinspection history. The company has a work force of 32 employees and operates on a seasonal basis, usuallyJune to November.Family Involvement: The next of kin information was obtained from the company and the CSHO telephonedto verify the information and advise the family that an investigation is in progress. The standard informationletter was sent. There has been no further Contact from the family.Union Involvement: There is no union at this location.Proposed Action: (The output!) Issue citations for serious and other violations of machine guarding, openfloor holes, hazard communication and recordkeeping with a penalty total of $5,475. A 5(a)(1) letteroutlining the hazards to be corrected which were not clearly addressed by 29 CFR 1928 Safety and HealthStandards for agriculture and for which other OSHA Standards are not applicable will also be mailed to thecompany.The six month date for this case is December 15, 1995The message in the above OSHA report is that, as required by the OSHA Act of 1970, OSHA agencies conductaccident investigation primarily to determine if violations in OSHA law caused the accident: To establishemployer liability, place blame, if you will. This is OSHAs mandate.This is not your organizations mandate... Read on...
  11. 11. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 11 of 71The employers mandate: Investigate and analyze to fix the system... not the blameUnfortunately, some employers believe that the investigation process ends once the blame has beenestablished. The problem, however, is that once the purpose of the analysis process has been achieved,analysis stops. When employers investigate to place blame, effective analysis to fix the system does notgenerally occur.According to OSHAs Safety & Health Program Management Guidelines, the employers primary purpose forinvestigating accidents is primarily, "so that their causes and means for preventing repetitions areidentified."OSHA goes on to say this about the investigation process:"Although a first look may suggest that employee error is a major factor, it is rarely sufficient to stop there.Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thoroughanalysis will generally reveal a number of deeper factors, which permitted or even encouraged an employeesaction. Such factors may include a supervisors allowing or pressuring the employee to take short cuts in theinterest of production, inadequate equipment, or a work practice which is difficult for the employee to carryout safely. An effective analysis will identify actions to address each of the causal factors in an accident ornear miss incident."Bottom line. The output of the employers accident investigation process should not end with merelyidentifying violations of employer safety rules. The end product should identify the root causes: the safetymanagement system weaknesses. In the most effective employer accident investigations, the question ofliability (fault, blame) should be addressed only if an honest post-investigation evaluation concludes that nosafety management system weaknesses contributed to the accident.Characteristics of an effective accident investigation program• The program will be guided by standard written procedures. Its important to make sure proceduresare clearly stated and easy to follow in a step-by-step fashion.• Clearly assigned responsibility for accident investigation. Its up to the employer to determine whoconducts accident investigations. Usually a supervisor, management/labor team, or safety committeemember conducts the investigation. Whoever conducts the investigation needs to understand his orher role as an accident investigator. Usually, two heads work better than one, especially whengathering and analyzing material facts about the accident. We recommend a team approach.
  12. 12. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 12 of 71• All accident investigators will be formally trained on accident investigation techniques andprocedures. Investigators may attend accident investigation training presented by OSHA, privateeducational institutions, or in-house training conducted by a qualified person.• Accident investigation must be perceived as separate from any potential disciplinary proceduresresulting from the accident. The purpose of the accident investigation is to get at the facts, not findfault. The accident investigator must be able to state with all sincerity, that he or she is conductingthe investigation only for the purpose of determining cause, not blame.• The accident investigation report will be in writing and will make sure that the surface causes androot causes of accidents are addressed. Most accident reports are ineffective precisely because theyneglect to uncover the underlying reasons or factors that contribute to the accident. Only by diggingdeep, can you eliminate the hazardous conditions and work practices that, on the surface, caused theaccident.• The accident investigation report will make recommendations to correct hazardous conditions andwork practices, and those underlying contributing factors that allowed them to exist. In manyinstances, the surface causes for the accidents are corrected on the spot, and will be reported assuch. But the investigator must make recommendations for long-term corrections in the safety andhealth system to make sure those surface causes do not reappear.• Follow-up procedures to make sure short and long-term corrective actions are completed.• An annual review of accident reports. A couple of safety committee members evaluate accidentreports for consistency and quality. They must make sure root causes are being addressed andcorrected. Information about the types of accidents, locations, trends, etc., can be gathered.
  13. 13. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 13 of 71Module 1 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. According to the text, an accident is the _______ in _______ process.a. end result, a plannedb. final event, an unplannedc. expected outcome, an unsafed. unexpected happening, a hazardous2. Accidents are usually caused by a lack of common sense.a. Trueb. False3. The employers mandate when conducting accident investigations is to investigate to ______.a. determine fault, not the causeb. fix the fault to establish accountabilityc. fix the system, not the blamed. any of the above is a valid mandate4. Employers with a healthful attitude about accidents consider them to be excusable.a. Trueb. False
  14. 14. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 14 of 715. Which of the following are characteristics of an effective accident investigation program?a. standard written proceduresb. investigators will be formally trainedc. surface causes for the accidents are corrected on the spotd. all of the aboveGo online and submit your quiz to receive the correct “book” answers.
  15. 15. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 15 of 71Module 2: Initiating the InvestigationWhy conduct the investigation?The accident investigation process we will discuss in this course will make sense if you understand thatultimately, the purpose of the investigation is to improve the safety management system. If you conduct theinvestigation for any other reason, it will likely result in ineffective solutions.In this module, well discuss a six-step process for conducting accident investigations.• Secure the accident scene• Conduct interviews• Develop the sequence of events• Conduct cause analysis• Determine the solutions• Write the reportLets get started!The first step in an effective accident investigation procedure is to secure the accident scene as soon aspossible so that we can accurately gather facts. At this point, you are not yet interested in what "caused" theaccident. Instead, you should focus on making the accident scene secure so that you can gather as muchpertinent information as possible.To secure the accident scene, simply use yellow caution tape, place warning cones, or post a guard to keeppeople away.When should you secure the accident scene?Thats a good question, and the basic answer is that you should begin when it is safe to do so. As the accidentinvestigator, you dont want to get in the way of emergency responders. Its also not safe to start if hazardshave not been properly mitigated.
  16. 16. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 16 of 71Why secure the accident scene?Thats a good question. Its always important to know why weare doing something, isnt it? In this situation, we need toprevent material evidence from being removed or relocated insome way. This is especially true if the accident is a reportable(serious or fatal) injury that might trigger an OSHA accidentinvestigation.Remember, at the request of OSHA, the employer must mark for identification, materials, tools orequipment necessary to the proper investigation of an accident. It is important that material evidence doesnot somehow get lost or "walk off" the scene.Two things may disappear after an accident occursMaterial evidence. Material evidence is anything that might be important in helping us find out whathappened. Somehow, tools, equipment, and other items just seem to move. The employer is anxious to"clean up" the accident scene so that people can get back to work. Its important to develop a procedure toprotect material evidence so that it does not get moved or disappear. If evidence disappears, Im sure youcan see why it might be difficult to uncover the surface causes for the accident. If you cant uncover thesurface causes, it will be almost impossible to discover and correct the root causes. Well talk more aboutsurface and root causes later in the course.Memory. Accidents are traumatic events that result in both physical and psychological trauma. Of course,there may be physical trauma to the victim and others. Varying degrees of psychological trauma may alsoresult depending on how "close" an individual is to the accident or victim. Everyone is affected somehow. Asthe length of time after an accident increases, thoughts and emotions distort what people believe they sawand heard. Conversations with others further distort reality. After a while, the memory of everyoneassociated in any way with the accident will be altered in some way. With that in mind, its important to getwritten statements and conduct interviews as soon as possible.
  17. 17. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 17 of 71Reporting accidents to OSHAIf your company is in the private sector, and a serious accident or fatality occurs, you may be required toreport it to your State or Federal OSHA office.Lets take a look at the OSHA Standard 29 CFR 1904.39, Reporting of Fatality or Multiple HospitalizationIncidents to OSHA, for the specific requirements.1904.39, Reporting of Fatality or Multiple Hospitalization Incidents to OSHA(a) Basic requirement.Within eight (8) hours after the death of any employee from a work-related incident or the in-patienthospitalization of three or more employees as a result of a work-related incident, you must orally report thefatality/multiple hospitalization by telephone or in person to the Area Office of the Occupational Safety andHealth Administration (OSHA), U.S. Department of Labor, that is nearest to the site of the incident. You mayalso use the OSHA toll-free central telephone number, 1.800.321.OSHA (1.800.321.6742).(b) Implementation—(1) If the Area Office is closed, may I report the incident by leaving a message on OSHAs answeringmachine, faxing the area office, or sending an e-mail? No, if you cant talk to a person at the AreaOffice, you must report the fatality or multiple hospitalization incident using the 800 number.What information do I need to give to OSHA about the incident?(2) You must give OSHA the following information for each fatality or multiple hospitalizationincident: establishment name; location of the incident; time of the incident; number of fatalities or hospitalized employees; names of any injured employees; Your contact person and his or her phone number; and A brief description of the incident.
  18. 18. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 18 of 71(3) Do I have to report every fatality or multiple hospitalization incident resulting from a motor vehicleaccident? No, you do not have to report all of these incidents. If the motor vehicle accident occurs on apublic street or highway, and does not occur in a construction work zone, you do not have to report theincident to OSHA. However, these injuries must be recorded on your OSHA injury and illness records, if youare required to keep such records.(4) Do I have to report a fatality or multiple hospitalization incident that occurs on a commercial or publictransportation system? No, you do not have to call OSHA to report a fatality or multiple hospitalizationincident if it involves a commercial airplane, train, subway or bus accident. However, these injuries must berecorded on your OSHA injury and illness records, if you are required to keep such records.(5) Do I have to report a fatality caused by a heart attack at work? Yes, your local OSHA Area Office directorwill decide whether to investigate the incident, depending on the circumstances of the heart attack.(6) Do I have to report a fatality or hospitalization that occurs long after the incident? No, you must onlyreport each fatality or multiple hospitalization incident that occurs within thirty (30) days of an incident.(7) What if I dont learn about an incident right away? If you do not learn of a reportable incident at thetime it occurs and the incident would otherwise be reportable under paragraphs (a) and (b) of this section,you must make the report within eight (8) hours of the time the incident is reported to you or to any ofyour agent(s) or employee(s).If you live in a "State Plan" state, your state OSHA accident reporting requirements may be different, so besure to check them out.Well, that wasnt too bad, was it? Now its time for your second module quiz. This quiz will help you reviewsome of the important points about securing the accident scene and initiating the investigation. If you find itdifficult to answer the questions, just review the material. I do not "grade" the quiz, so dont worry aboutthat. Also, I just want to remind you that the final exam questions are based on the questions within eachmodule, so study the quiz questions.
  19. 19. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 19 of 71Module 2 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. The purpose of an accident investigation includes all of the following, except:a. uncover surface and root causesb. improve safety in designc. determine faultd. make safety program improvements2. Which of the following are methods used to secure the accident scene?a. use yellow caution tapeb. place conesc. post a guardd. any of the above may be used3. What might be the result if the investigation is not initiated as soon as possible?a. memory about what happens disappearsb. material evidence is moved or removedc. more difficult to uncover the factsd. all of the above might result
  20. 20. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 20 of 714. If a workplace fatality occurs, the affected employer must notify OSHA within _____ hrs.a. 24b. 16c. 8d. 45. The fatality report to OSHA would include all of the following except.a. Name of witness(s)b. Name of the establishmentc. Location of incidentd. Contact persone. Description of the incidentGo online and submit your quiz to receive the correct “book” answers.
  21. 21. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 21 of 71Module 3: Documenting the Accident SceneDocument before it goes away...In this module we will take a look at strategies for documenting the accident scene. Well emphasize theteam approach and discuss the advantages of using the various documentation methods including, personalobservation, photo/videotaping, taking statements, drawing sketches and reviewing records.Why the team approach works bestOnce the accident scene has been roped off, its important to begin immediately to gather evidence from asmany sources as possible during an investigation. One of the biggest challenges youll face as an investigatoris to determine what information is relevant. You want data that will help you determine what happened,how it happened, and why it happened. Identifying items that answer these questions is the purpose ofdocumenting the accident scene.You wont be able to document the scene effectively unless you come prepared, so make sure you have puttogether an accident investigation kit for use during the investigation. As youll learn, there are many ways todocument the scene, so it may become quite difficult for one person to effectively complete all actions. Themost effective strategy is to document as much as possible, even if you dont think the information may notbe relevant. Its easy to discard clues or leads later if they prove to not be useful to the investigation. Its notat all easy to dig up material evidence late into the investigation. All items found at the scene should beconsidered important and potentially relevant material evidence. Consequently, a team approach is probablythe most efficient strategy to use when investigating serious accidents.Methods to document the accident sceneLets talk about the various methods you can use to document the accident scene.
  22. 22. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 22 of 71Make personal observationsWith clipboard in hand, take notes on personal observations. Try to involve all of your senses (sight, hearing,smell, etc.). What do you see? What equipment, tools, materials, machines, structures appear to be broken,damaged, struck or otherwise involved in the event? Look for gouges, scratches, dents, smears. Ifvehicles are involved, check for tracks and skid marks. Look for irregularities on surfaces. Are thereany fluid spills, stains, contaminated materials or debris? What about the environment? Were there any distractions, adverse conditions caused by weather?Record the time of day, location, lighting conditions, etc. Note the terrain (flat, rough, etc.). What is the activity occurring around the accident scene? Who is there: Who is not? Youll need this information to take initial statements and interviews. Measure distances and positions of anything and everything you believe to be of any value to theinvestigation.Get initial statementsIf you are fortunate there will be one or more eye-witnesses to the accident. Ask them for an initialstatement giving a description of the accident. Also try to obtain other information from the witnessincluding: names of other possible witnesses for subsequent interviews; names of company rescuers or emergency response service; and materials, equipment, articles that may have been moved or disturbed during the rescue.Take photos of the accident sceneWhen taking photos, make sure you start with distance shots, and gradually move in closer as you take thephotos. Below are some important points to remember about taking photos. Take photos at different angles (from above, 360 deg. of scene, left, right, rear) to show therelationship of objects and minute and/or transient details such as ends of broken rope, defectivetools, drugs, wet areas, containers. Take panoramic photos to help present the entire scene, top to bottom - side to side.
  23. 23. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 23 of 71 Take notes on each photo. These will be included in the appendix of the report along with the photos.Identify the type of photo, date, time, location, subject, weather conditions, measurements, etc. Place an item of known dimensions in the photo if hard-to-measure objects are being photographed. Identify the person taking the photos. You may want to indicate the locations at which photos were taken on sketches.Take video clips of the sceneThere is no requirement to take video. However, with the video capability of digital cameras, its becomingmore common to use this method. If you are planning to take video, the earlier you can begin the better.Once the emergency responders are attending to the victim, begin taking video. The video recorder will pickup details and conversations that can add much valuable information to your investigation. Just remembernot to get in the way. Below are some important points to remember when videotaping. Have each witness accompany you and privately describe what happened while taking video. If possible, try to reenact the event. To get the "lay of the land," stand back from a distance and zoom in to the scene. Scan slowly 360 degrees left and right to establish location. Narrate what is being viewed: describe objects, size, direction, and location, etc. If a vehicle was involved, video the direction of travel, going and coming.Before you take video, make sure your video camera is operating properly, the battery is charged, and, ohyes...take the cap off the lens ;-)Sketch the accident sceneSketches are very important because they compliment the information in photos, and are good at indicatingdistances between the various elements of the accident. This is important to do because it establishes"position evidence." It is important to be as precise as possible when making sketches. Below you will findthe basic components of a sketch. Documentation. Date, time, location, identity of objects, victims, etc. Spatial relationships. Measurements. Location of photographs.
  24. 24. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 24 of 71Sketches are also valuable because they reconstruct the accident in model form and effectively showmovement through time. Sketches also help establish testimony if it becomes necessary to defend against adamage or injury claim. The sketch may also help establish a claim against a supplier or manufacturer.You dont have to be a professional illustrator to make a decent sketch, but you must be accurate in yourmeasurements. Take a look at the sketch below as a sample of a useful sketch.Some sketching pointers Make sketches large; preferably 8" x 10". Makes sketches clear. Include information pertinent to the investigation. Include measurements. Establish precise fixed identifiable reference points. Print legibly. All printing should be on the same plane. Indicate directions: N,E,S,W. Always tie measurements to a permanent point, e.g. telephone pole, building. Mark where people were standing. Use an arrow to show direction of motion Use sketches when interviewing people. Show where photos were taken.
  25. 25. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 25 of 71The first sketch to the right illustrates theTriangulation Method which makes it possible tolater pinpoint the exact location of an object. In thisaccident, the victim Contacted a high voltage linewith a metal tree trimming pole. The position of thevictims head is measured from three points. Noticethe small circles with horizontal lines through them.These circles indicate where photos were taken.Also, North is indicated and all major objects areidentified.The second sketch illustrates one of the majoradvantages of sketching. It shows motion through time.In this sketch you can see the direction the deceased andthe bulldozer were travelling shortly before the accidentand at the time of the accident.
  26. 26. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 26 of 71Interview recordsThats right...you dont just review records, you "interview" them by asking them questions. If you ask...theywill answer. Below are some of the records you may want to interview. Maintenance records Training records Standard operating procedures Safety policies, plans, and rules Work schedules Personnel records Disciplinary records Medical records (if permission granted, or otherwise allowed.) EMT reports OSHA 300 Log OSHA Form 301, Injury and Illness Incident Report Safety committee minutes Coroners report Police reportFinal words…Documenting the scene is important for so many reasons. Remember, the team approach works bestbecause accuracy in reconstructing the accident is the final criteria. I think youll agree that given all the timeand money constraints, and complexity of the investigation process, two heads are better than one. Nowlets take the quiz.
  27. 27. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 27 of 71Module 3 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. When documenting the scene, one of the biggest challenges facing the investigator is to determine...a. determine who is to blameb. determine whats relevantc. determine whos in charged. determine who is liable2. The most effective documentation strategy is to...a. document material evidenceb. document obviously relevant materialc. document it, even if relevancy is in questiond. document evidence to establish relevancy3. When making personal observations, the investigator should consider which of the following:a. What is not presentb. Condition of objectsc. What is presentd. All of the above4. Photos are better at documenting the scene for all the reasons below except:a. Photos more effectively show motion through time.b. Photos are better at displaying details.
  28. 28. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 28 of 71c. Photos best show size relationships.d. Photos are easier to produce.5. Which of the documents below is least likely to be "interviewed" as part of the investigation process fora minor injury?a. training recordsb. maintenance recordsc. police recordsd. inspection recordsGo online and submit your quiz to receive the correct “book” answers.
  29. 29. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 29 of 71Module 4: Conducting Effective InterviewsDigging up the facts can be a challengeAfter you have initially documented the accident scene, the next step is to start digging for additional detailsby conducting interviews.This activity is perhaps the most difficult part of an investigation. This module will help you understand howto set up an interview and develop interview questions. The module will also discuss how to organize theinterview and the participants to most effectively get accurate information.Steves Seven "Rights" of the interview processThe purpose of the accident investigation interview is to obtain an accurate and comprehensive picture ofwhat happened. To do that, the interviewer must demonstrate personal leadership and skill in conductingthe interview. Since leadership is all about doing the right thing, I came up with seven "rights" to help usremember what we should do to make sure the interview process is effective. So, here are those sevenrights...Be sure you ask the...1. Right people the2. Right questions at the3. Right time in the4. Right place in the5. Right way for the6. Right reason to uncover the7. Right factsCooperation is the Key!Cooperation not intimidation is the key to a successful accident investigation interview. Its verycounterproductive to give the impression in any way that can be interpreted by the interviewee as trying toestablish blame. The purpose of the accident interview is to uncover additional information about thehazardous conditions, unsafe work practices, and related system weaknesses that contributed to the
  30. 30. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 30 of 71accident. Consequently, its very important that effective techniques to establish trust and a cooperativeatmosphere be used by the interviewer during the process.What are effective ways to increase cooperation in the accident interview process? What communicationstrategies might increase the likelihood of an adversarial relationship in the interview? As you conductinterviews, gaining experience along the way, youll further develop the "art" of interviewing by improvingyour ability to apply these techniques.Preparing for the interviewYour first task is to determine who needs to be interviewed. You will need to design your questions aroundthe interviewee. Consequently, each interview will be a very unique experience. Interviews should occur assoon as possible, but usually they do not happen until things have settled down just a bit. Below are some ofthe people you may want to consider interviewing. The victim. To determine the immediate events leading up to and including the accident. Co-workers. To establish what actual vs. appropriate procedures are being used. Direct supervisor. To get background information on the victim. He or she can provide proceduralinformation about the task that was being performed, the training provided, workload, scheduling,and resources being provided. Manager. To get information on related operational and safety management programs/systems. Training department. To get information on quantity and quality of training the victim and othershave received. Personnel department. To get information on the victims and other employees work history,discipline, appraisals. Maintenance personnel. To determine background on corrective and preventive maintenance. Emergency responders. To learn what they saw and did when responding to the accident. Medical personnel. To get medical information (as allowed by law.) Coroner. Can be a valuable source to determine type/extent of fatal injuries. Police. If they filed a report. Other interested persons. Anyone interested in the accident may be a valuable source ofinformation. The victims spouse and family. They may have insight into the victims state of mind or other workissues.
  31. 31. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 31 of 71Effective Interviewing TechniquesAn important aspect of your job, as the interviewer, is to construct a composite story or "word picture" ofwhat happened using the various accounts of the accident and other evidence. To do that, you will need tounderstand effective interview techniques and be able to skillfully apply those techniques.Its important to remember that you are conducting an accident investigation, not a criminal investigation.These two interview processes may be similar, but each has a unique purpose. Each process requiresdifferent techniques to achieve the intended purpose. The last thing you want to do in an accidentinvestigation is to come down hard (be accusatory) on an interviewee. So lets take a look at some effectivetechniques that will assure you get to the facts...not find fault. Keep the purpose of the investigation in mind: To determine the cause of the accident so that similaraccidents will not recur. The interview process is not conducted to determine liability, but todetermine the facts so that any and all safety management system design and implementationweaknesses can be improved. Make sure the interviewee understands this: "We dont want you oranyone else to get hurt like this again." First, ask for background information like name, job, and phone number. Then, simply have thewitness tell you what happened. Let them talk, and you just listen. Dont ask them "if" they canexplain what happened, because they may respond with a simple "no," and thats that. Approach the investigation with an open mind. It will be obvious if you have preconceptions aboutthe individuals or the facts. Go to the scene. Just because you are familiar with the location or the victims job, dont assume thatthings are always the same. If you cant conduct a private interview at the location, find an office ormeeting room that the interviewee considers a "neutral" location. Put the person at ease. Explain the purpose and your role. Sincerely express concern regarding theaccident and desire to prevent a similar occurrence. Tell the interviewee that the information they give is important. Its important to say its "important". Be friendly, understanding, and open minded. Be calm and unhurried. Dont ask leading questions; dont interrupt; and dont make expressions (facial, verbal of approval ordisapproval). Do ask open-ended questions to clarify particular areas or get specifics. Try to avoid closed-endedquestions that require a simple yes and no answer. Try to avoid asking "why-you" questions as these
  32. 32. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 32 of 71type of questions tend to make people respond defensively. Example: Do not ask: "Why did you drivethe forklift with under-inflated tires? Rather, ask: What are forklift inspection procedures? or "Tell meabout the forklift inspection procedure." Repeat the facts and sequence of events back to the person to avoid any misunderstandings. Notes should be taken very carefully, and as casually as possible. Let the individual read your notes sothat they can possibly fill in missing information and correct inaccuracies. Give the interviewee a copyof the notes. Have the interviewee initial that they have read and found the notes accurate. Dont use a tape recorder unless you get permission. Tell the interviewee that the purpose of therecorder is to make sure the information is accurate. Offer to give the interviewee a copy of the tape. If the interviewee wants to have someone witness the interview, thats fine. In most unionenvironments, this is an employee right. Ask for the interviewees opinion about what caused the accident and what can be done to make sureit doesnt happen again. Do not accept answers that accuse or place blame. Note: There is neverenough information to establish blame at this phase of the investigation. Only after the investigationis complete and closed out will the need for discipline be discussed, and thats usually theresponsibility of the supervisor and the Human Resource Department, not the accident investigator. Conclude the interview with a statement of appreciation for their contribution. Ask them to contactyou if they think of anything else. If possible, relay the outcome of the investigation to each personwho was interviewed. Again, do not discuss the possibility of disciplinary action.Final words...Understanding and applying the information above during the interview process will help establish a highlevel of trust and a cooperative relationship so that you can get to the facts. Remember, intimidation andplacing blame has no place in the accident investigation process and besides, it just doesnt work.Okay, now that you are an ace interviewer, its time to take the module quiz ;-)
  33. 33. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 33 of 71Module 4 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. What is the purpose of the interview process.a. satisfy OSHA investigation requirementsb. determine who is to blame quicklyc. determine the cause of the accidentd. cover your rear end2. Which of the following is an effective interview technique?a. Ask "why-you" questionsb. Ask open-ended questionsc. Blow smoke in their faced. Encourage fault-finding3. Which of the following locations might be best for conducting the interview?a. The scene of the accidentb. The supervisors officec. The lunch roomd. At a restaurant4. Why is it important to ask the interviewee to review the interview notes?a. to keep them confidentialb. to shape interviewee thinking
  34. 34. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 34 of 71c. they can make sure the right person is blamedd. they can correct inaccuracies5. What happens when you interview several persons in presence of each other?a. the others stories change with each interviewees accountb. others will remember more with each interviewc. each interviewee will more likely be accurate with each storyd. each interviewee feels more comfortable telling their storyGo online and submit your quiz to receive the correct “book” answers.
  35. 35. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 35 of 71Module 5: Conducting Event AnalysisIntroductionThis module introduces you to the concepts of assessment and analysis as they relate to the accidentinvestigation process. Well review some theories of accident causation and discuss the process ofdeveloping and analyzing the sequence of events occurring prior to, during, and immediately after anaccident.Sorting it all out...So far, you have collected a lot of factual data and its strewn all over your desk. The task now is to turn thatdata into useful information. Youve got to somehow take this data and make some sense of it. Its importantto know that youre not gathering all of this information just to conduct an assessment of what was and wasnot present immediately prior to the accident. Youre actually conducting an analysis to determinespecifically how behaviors and conditions, and the underlying system weaknesses contributed to theaccident. To better understand this, lets take a closer look at what the process of "analysis" is.Analysis definedWebster defines analysis as the, "separation of an intellectual or substantial whole into its parts forindividual study."When an accident occurs, we need to separate or "break down" the "whole" accident process into itscomponent "parts" for study to determine how they relate to the whole accident. Since the accident, itself, isthe main event, its component parts may be thought of as the individual events leading up to and includingthe main event or the accident. The accident investigators challenge is to effectively assess each event toidentify the presence or absence of behaviors and conditions, and then analyze those behaviors andconditions in each event to determine if and how they contributed to the accident. To do this we need tomake some basic assumptions about the factors that cause or contribute to accidents.
  36. 36. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 36 of 71Why accidents happenOver the past century, safety professionals have tried to more effectively explain how and why accidentsoccur. During the early years the initial explanations were at first rather simplistic. Theorists graduallyrealized that it was not sufficient to explain away workplace accidents as simple cause-effect events. Theydeveloped new theories that better explained as the result of complicated interactions taking place amongconditions, behaviors and systems. With this in mind, lets take a look at some of these theories.Single Event Theory"Common sense" leads us to this explanation. An accident is thought to be the result of a single, one-timeeasily identifiable, unusual, unexpected occurrence that results in injury or illness. Some still believe thisexplanation to be adequate. Its convenient to simply blame the victim when an accident occurs. Forinstance, if a worker cuts her hand on a sharp edge of a work surface, her lack of attentiveness may beexplained as the cause of the accident. ALL responsibility for the accident is placed squarely on the shouldersof the employee. An accident investigator who has adopted this explanation for accidents will never lookbeyond perceived personal employee flaws to discover the underlying system weaknesses that may havecontributed to the accident.The Domino TheoryThis explanation describes an accident as a series of related occurrences which lead to a final event whichresults in injury or illness. Like dominoes, stacked in a row, the first domino falling sets off a chain reaction ofrelated events that result in an injury or illness. Theaccident investigator will assume that by eliminating anyone of those actions or events, the chain will be brokenand the future accident prevented. In the example above,the investigator may recommend removing the sharpedge of the work surface (an engineering control) toprevent any future injuries. This explanation still ignoresimportant underlying system weaknesses or root causesfor accidents.
  37. 37. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 37 of 71Multiple Cause TheoryThis explanation takes us beyond the rather simplistic assumptions of the single event and domino theories.Once again, accidents are not assumed to be simple events. They are the result of a series of random relatedor unrelated actions that somehow interact to cause the accident. Unlike the domino theory, the investigatorrealizes that eliminating one of the events does not assure prevention of future accidents. Removing thesharp edge of a work surface does not guarantee a similar injury will be prevented at the same or otherworkstation. Many other factors may have contributed to an injury. An accident investigation will not onlyrecommend corrective actions to remove the sharp surface, it will also address the underlying systemweaknesses that caused it.The final event in an unplanned processWhen we understand that the accident, itself, is actually the final event in a complex series of events, wellnaturally want to know what the initiating events were. When the initiating events occur, they effect, in oneway or another, the workplace conditions and actions of others, setting in motion a potentially verycomplicated process that eventually ends in an injury or illness. The trick is to take the information gatheredand arrange it so that we can accurately determine what initial conditions and/or actions transformed theplanned work process into an unintended accident process.Four categories of eventsIn this step, take the information you have gathered to determine the events prior to, during, and after thenear miss/injury accident. It is important to note that a serious injury accident can easily be the result of 20or more events. Events can occur anytime, anywhere, any place, and to anyone. It is possible that pertinentevents may have occurred many weeks or months before the accident.
  38. 38. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 38 of 71There are four categories of events:1. Actual Events. These are events that you are able to determine actually occurred i.e., an event that iswitnessed by one or more persons (two or more is best) and they can verify it actually happened. Youwould want to interview all witnesses to the event.Example: Bob and Bobbie saw Robert turn off the chipper power switch and then walk overand reach into the chipper in an attempt to remove some jammed wood.2. Assumed Events. These are events that must have happened but have not yet been verified. Flagthese somehow to remind you that more investigation is needed. Assumed events are harder toestablish. In any step-by-step process, you cant get to step 3 without first doing the first two steps. Ifa worker is injured at step 3, you may assume he accomplished steps 1 and 2 unless, it is establishedthat he bypassed the first two steps. If completing steps 1 and 2 will prevent an injury at step 3, youmay assume the worker did not do steps 1 or 2.Example: If Roberts hand was crushed while clearing a piece of wood that was stuck in a largechipper, we may assume he did not perform lockout/tagout, or we may assume that heperformed lockout/tagout incorrectly. Only further investigation and analysis will uncoverwhat actually happened.3. Non-Events. If an event was supposed to happen, but did not, that is a non-event. Although non-events describe an event that did not occur, they should be captured because they may help discoverconditions and behaviors relevant to the investigation.Example: Robert did not try to start the chipper to verify lockout/tagout was successfullyperformed. He failed to perform the verification step of the lockout/tagout procedure.4. Simultaneous Events. In some accidents scenarios two or more events occur at precisely the sametime resulting in a hazardous condition or set of unsafe behaviors that cause an injury.Example: Ralph wondered why the chipper was off and turned it back on at the same instant intime that Robert reached into the chipper to remove the jammed wood.
  39. 39. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 39 of 71Developing the sequence of eventsOur challenge at this point in the investigation process is to accurately determine the sequence of eventsleading up to the accident so that we can more effectively understand why the accident event, itself,happened. Once the sequence of events is developed, we can then study each event in the sequence todetermine the related elements below. Hazardous conditions. Objects and physical states that directly caused or contributed to the accident. Unsafe behaviors. Actions taken/not taken that directly caused or contributed to the accident. System weaknesses. Underlying inadequate or missing policies, programs, plans, processes,procedures and practices that contributed to the accident.(Hold on... well study more about these three elements in the next module.)In the multiple-cause approach to accident investigation, many events may occur, each somehowcontributing to the final event. For instance, if a supervisor ignores an unsafe behavior because doing so isnot thought to be his or her responsibility, the failure to enforce safe behavior represents an event in theproduction process that may contribute to or increase the probability of a future accident.The two components of an event: The Actor and the ActionEach event in the unplanned accident process is composed of an actor and an action, so lets take a look ateach. Actor. The actor is an individual or object that directly influenced the flow of the sequence of events.An actor may participate in the process or merely observe the process. An actor initiates a change byperforming or failing to perform an action. Action. An action is "the something" that is done by an actor. Actions may or may not be observable.An action may describe a behavior that is accomplished or not accomplished. Failure to act should bethought of as an act, just as much as an act that is accomplished.Its important to understand that when describing an event in writing, first identify the actor and then tellwhat the actor did. Remember, the actor is the "doer," not the person or object being acted upon orotherwise having something done to them. For instance, take a look at the event statement below:
  40. 40. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 40 of 71"Bob unhooked the lifeline from the harness."In this example, "Bob" is the actor and "unhooked" describes the action. First we describe the actor...Bob.Next, we describe the action...unhooking. The lifeline and harness, although "objects" are not actors becausethey are not performing an action. Rather, something is being done to them. Also note that the statement iswritten in active tense.Sample sequence of eventsTo get a good idea of what the sequence of events looks like, review the example below that was preparedfor an actual fatality investigation conducted by an OSHA accident investigator a few years ago.1. Employee #1 returned to work at 12:30 PM after lunch to continue laying irrigation pipes.2. At approximately 12:45 PM employee #1 began dumping accumulated sand from an irrigation mainlinepipe.3. Employee #1 oriented the pipe vertically and it contacted a high voltage power line directly over the workarea.4. Employee #2 heard a ‘zap’ and turned to see the mainline pipe falling and employee #1 falling into anirrigation ditch.5. Employee #2 ran to employee #1 and pulled him from the irrigation ditch, laid him on his back and ranabout 600 ft to his truck and placed a call for help on his mobile phone.6. Employee #2 then ran back to find employee #1 had fallen back into the ditch.7. Employee #2 jumped back into the ditch and held employee #1 out of the water until help arrived.8. Two other ranch employees arrived and assisted employee #2 in getting employee #1 out of the ditch.9. Approximately one minute later, paramedics arrived and began to administer CPR on employee #1. Theyalso used a heart defibrillation machine in an attempt to stabilize employee #1’s heart beat.10. At approximately 1:10 PM an ambulance arrived and transported employee #1 to the hospital where hewas pronounced dead at 1:30 PM.
  41. 41. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 41 of 71Paint a word pictureIts important that the sequence of events clearly describe what occurred so that someone who is unfamiliarwith an accident is able to "see it happen" as they read the narrative.Sample sequence of eventsHere is another example that shows how a sequence of events can be developed using cards. Describe eachevent and then arrange the events on your desk or a wall in the proper sequence.
  42. 42. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 42 of 71Make sure you are constructing only one eventIf an event is hard to understand, it may be that the description is too vague or general. The solution to thisproblem is to increase the detail. We can use two strategies to increase detail:1. Look around. Determine if anything else was said/done before or after the event you’re currentlyassessing.2. Separate the actors. Remember, an actor may be a person or a thing accomplishing a given action. Ifan event includes actions by more than one actor, break the event down into two events. If the eventcontains the conjunction, "and," the event is likely to be a combination of two events. If you look atthe sample sequence of the events from 5.9 and 5.10, Im sure you can spot a few combined events.Final words...Well, that was a good introduction to the idea of constructing the sequence of events. Just remember, theaccuracy of your investigation will be greater by following this procedure. Okay, thats it. It’s time to take thequiz.
  43. 43. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 43 of 71Module 5 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. (fill in the blanks) _______________ determines presence/absence. ____________ breaks down thewhole into parts to see how they each relate to the whole.a. Evaluation, Analysisb. Analysis, Assessmentc. Assessment, Analysisd. Analysis, Evaluation2. Once the sequence of events is developed, the investigator will study each event to determine all of thefollowing, EXCEPT:a. hazardous conditionsb. unsafe behaviors/actionsc. system weaknessesd. personal fault3. Which theory below states that eliminating one event does not assure prevention of future accidents?a. Single event theoryb. Domino theoryc. Multiple cause theoryd. System weakness theory4. In the event statement, "Robert pounded a nail with a broken hammer," ________ is the actor and________ is the action.a. Broken hammer, pounded a nailb. Nail, with a broken hammerc. Robert, pounded a naild. Robert, with a broken hammer
  44. 44. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 44 of 715. In this event statement, "The wrench struck Roberts hand," ________ is the actor and _________ is theaction.a. struck, wrenchb. struck, Robertc. Robert, struckd. wrench, struckGo online and submit your quiz to receive the correct “book” answers.
  45. 45. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 45 of 71Module 6: Determining the CausesIntroductionYouve gathered information and used it to develop an accurate sequence of events. You have a goodmental picture of what happened. Now its time to conduct an analysis of each event to determine causes.This module will introduce us to the concepts below. Direct cause of injury Surface cause of the accident Root cause of the accident Injury analysis Surface cause analysis Root cause analysisThe harmful transfer of energy is the direct cause of injuryIts important to understand that all injuries to workers are caused by one thing: the harmful transfer ofenergy. Lets take a look at some examples that illustrate this important principle.• If a harsh acid splashes on your face, you may suffer a chemical burn because your skin has beenexposed to a chemical form of energy that destroys tissue. In this instance, the direct cause of theinjury is a harmful chemical reaction. The related surface causes might be the acidic nature of thechemical (condition) and working without proper face protection (unsafe behavior).• If your workload is too strenuous, force requirements on your body may cause a muscle strain. Here,the direct cause of injury is a harmful level of kinetic energy (energy resulting from motion), causinginjury to muscle tissue. A related surface cause of the accident might be fatigue (hazardous condition)or improper lifting techniques (unsafe behavior).The important point to remember here is that the "direct cause" of the injury is not the same as the "surfacecause" of the accident event. The direct cause of injury is the harmful transfer of energy as a consequence of your exposure to thatenergy. The direct result of this harmful energy transfer is injury. The surface cause of the accident is the condition or behavior that interact in a way that results inthe harmful transfer of energy.
  46. 46. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 46 of 71Safety "engineers" closely analyze all the surface cause categories and attempt to: eliminate the harmful energy transfer, reduce the harmful energy transfer, or reduce exposure to harmful energy transfer.They do this through "safety by design" by designing safety features directly into tools, machinery,equipment, facilities, etc.The surface causes of accidentsThe surfaces causes of accidents are those hazardous conditions and unsafe or inappropriate behaviors thathave directly caused or contributed in some way to the accident.Hazardous conditions Are unique things or objects that are somehow defective or unsafe Are "states of being" such as employee fatigue May also be unique defects in processes, procedures or practices May exist at any level of the organization Are the result of deeper root causesHazardous conditions may exist in any of the categories below: Materials Machinery Equipment Tools Chemicals Environment Workstations Facilities People WorkloadUnsafe or inappropriate behaviors
  47. 47. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 47 of 71Its important to know that most hazardous conditions in the workplace are the result of the unsafe orinappropriate behaviors that produced them. Actions we take or dont take that increase risk of injury or illness May also be thought to be unique performance errors in a process, procedure or practice May exist at any level of the organization Are the result of deeper root causesBelow are some examples of unsafe or inappropriate employee/manager behaviors. Failing to comply with rules Using unsafe methods Taking shortcuts Horseplay Failing to report injuries Failing to report hazards Allowing unsafe behaviors Failing to train Failing to supervise Failing to correct Scheduling too much work Ignoring worker stressThe root causes of accidentsNow lets switch gears. Instead of talking about unique conditions and behaviors, lets look at the generalconditions and behaviors inherent in the safety management system. Oh yes... to me the safety managementsystem is "organic". By that I mean it is dynamic, ever-changing and behaves as though it were alive. Thinkabout it. If thats a little too metaphysical for you... read on.The root causes for accidents are the underlying safety management system weaknesses, which consist ofthousands of variables, any number of which can somehow contribute to the surface causes of accidents.These weaknesses can take two forms. System Design Root Causes. Inadequate design of one or more components of the safetymanagement system. The design of safety management system policies, plans, programs, processes,procedures and practices (remember this as the 6-Ps) is very important to make sure appropriateconditions, activities, behaviors, and practices occur throughout the workplace. Ultimately, mostsurface causes will lead to system design flaws. System Implementation Root Causes. Inadequate implementation of one or more components of
  48. 48. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 48 of 71the safety management system. Failure to effectively implement the safety management system iscritical to the success of the system. You may design an effective safety plan, yet suffer failurebecause it wasnt implemented properly. If you effectively implement a poorly written safety plan,youll get the same results. In either instance, youll eventually need to improve one or more policies,plans, programs, processes, procedures or practices.Safety managers work with safety engineers to eliminate or reduce exposure to hazards through effectivelyimproving safety system components. Because systems design work common throughout the workplace,eliminating any single root cause may simultaneously eliminate many hazardous conditions and unsafebehaviors.Since root causes reside within safety management systems, upper management -- those who formulatesystems, are most likely going to be involved in making the necessary improvements. When analyzing forsystem weaknesses, it may be beneficial to coordinate closely with those who will be responsible forimplementing system improvements.If you have Adobe Acrobat, take a look at the Accident Weed, an excellent analogy that helps us understandthe relationship between surface and root causes for accidents.Three levels of cause analysisAs mentioned earlier in the course, accidents are processes that culminate in an injury or illness. An accidentmay be the result of many factors (simultaneous, interconnected, cross-linked events) that have interacted insome dynamic way. In an effective accident investigation, the investigator will conduct three levels of causeanalysis:1. Injury analysis. At this level of analysis, we do not attempt to determine what caused the accident,but rather we focus on trying to determine how harmful energy transfer caused the injury.Remember, the outcome of the accident process is an injury.2. Event Analysis. Here you determine the surface cause(s) for the accident: Those hazardous conditionsand unsafe behaviors described throughout all events that dynamically interact to produce the injury.All hazardous conditions and unsafe behaviors are clues pointing to possible system weaknesses. Thislevel of investigation is also called "special cause" analysis because the analyst can point to a specificthing or behavior.
  49. 49. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 49 of 713. Systems analysis. At this level, youre analyzing the root causes contributing to the accident. You canusually trace surface causes to inadequate safety policies, programs, plans, processes, or procedures.Root causes always pre-exist surface causes and may function through poor component design toallow, promote, encourage, or even require systems that result in hazardous conditions and unsafebehaviors. This level of investigation is also called "common cause" analysis (in quality terms) becauseyoure identifying a system component that may contribute to common conditions and behaviorsthat exist or occur throughout the company.I think the greatest challenge to effective accident investigation is to transition fromevent analysis to systems analysis. Why? Because its hardly ever done.One last important point to make is that most accident processes are far more complex than you mightoriginally think. Some experts believe at least 10 or more factors come together to cause a serious injuryaccident. Other experts state that an average of 27 factors directly and indirectly contribute to a seriousaccident.Only by thoroughly conducting all three levels of analysis can you design system improvements thateffectively eliminate hazardous conditions and unsafe behaviors at all levels of the organization. The accidentinvestigation cannot serve as a proactive safety process unless system improvements effectively preventfuture accidents.Injury AnalysisIf you examine the surface cause categories in 6.3 and 6.4, you will find that each condition or behavior maysomehow result in the transfer of a harmful level of energy to a persons body causing injury. The severity ofthe injury depends on the magnitude of the harmful energy. Below are the various forms of energy that canbe harmful.Harmful forms of energy1. ACOUSTIC ENERGY - Excessive noise and vibration.
  50. 50. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 50 of 712. CHEMICAL ENERGY - Corrosive, toxic, flammable, or reactive substances. Involves a release of energyranging from "not violent" to "explosive" and "capable of detonation".3. ELECTRICAL ENERGY - Low voltage (below 440 volts) and high voltage (above 440 volts).4. KINETIC (IMPACT) ENERGY - Energy from "things in motion" and "impact," and are associated with thecollision of objects in relative motion to each other. Includes impact between moving objects, moving objectagainst a stationary object, falling objects or persons, flying objects, and flying particles. Also involvesmovement resulting from hazards of high pressure pneumatic, hydraulic systems.5. MECHANICAL ENERGY - Cut, crush, bend, shear, pinch, wrap, pull, and puncture. Such hazards areassociated with components that move in circular, transverse (single direction), or reciprocating motion.6. POTENTIAL (STORED) ENERGY - Involves "stored energy." Includes objects that are under pressure,tension, or compression; or objects that attract or repulse one another. Susceptible to sudden unexpectedmovement. Includes gravity - potential falling objects, potential falls of persons. Includes forces transferredbiomechanically to the human body during lifting.7. RADIANT ENERGY HAZARDS - Relatively short wavelength energy forms within the electromagneticspectrum. Includes infra-red, visible, microwave, ultra-violet, x-ray, and ionizing radiation.8. THERMAL ENERGY - Excessive heat, extreme cold, sources of flame ignition, flame propagation, and heatrelated explosions.Event AnalysisIn the last module you learned that each event in our sequence will include descriptions of actors and theiractions that may have contributed to the accident.Our next step is to examine each event to determine: the actor that represents a hazardous condition, and the action that represents an unsafe behavior.The hazardous conditions (actors) and unsafe behaviors (actions) we identify as contributing to the accidentare called the surface causes of the accident.
  51. 51. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 51 of 71After you identify surface causes, youll need to determine if inadequate safety system componentscontributed to the accident by allowing the hazardous conditions and unsafe behaviors to develop or occur.These system inadequacies are called the root causes of accidents. Lets take a closer look at these two veryimportant concepts.More on Event AnalysisWell, you know what surface and root causes are, and you know all about the three levels of analysisrequired for an effective investigation, but what techniques can you use to help conduct the analysis? Letstake a look at one technique that I have found efficient in conducting an event analysis.Ive used a "fishbone diagram" below to help you conduct an event analysis. Follow the steps below whenusing this tool.1. Get a sheet of paper.2. At the top of the sheet write "Accident Analysis". Doing this reminds you that you are breaking downthe process into a number of events.3. At the left side of the sheet, centered, write "The Injury".4. Extend a horizontal line out from the right of the box.5. Describe the injury event on the horizontal line.6. Identify and circle the actors and actions described in the event statement.7. Start asking why questions (at least five whys) about the actor and actions to uncover any hazardousconditions or unsafe behaviors.8. Draw lines either angling up or down from the circled actors and actions and write the answers toyour questions.9. Repeat these steps with each of the new level of answers.
  52. 52. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 52 of 71The diagram you produce using this procedure should look something like this. Each level of questioning willget you closer to the root cause(s) that contributed to the hazardous conditions or unsafe behaviors. Onceyou start identifying inadequate policies, programs, plans, processes, and procedures...you are getting to thereal root causes!Final words…Finally, its important to understand that most accidents in the workplace result from unsafe work behaviors.According to the latest research: unsafe behaviors represent the primary surface cause for about 95% of all workplace accidents; hazardous conditions represent the primary surface cause for only about 3% of workplace accidents;and uncontrollable (unknowable) causes account for the remaining 2%.These statistics imply that management system weaknesses contribute in some way for fully 98% (conditions+ behaviors) of all workplace accidents.To effectively fulfill your responsibilities as an accident investigator, you must not close the investigationuntil these root causes and solutions have been identified.Whew! That was a lot to take in. Time for the quiz!
  53. 53. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 53 of 71Module 6 QuizUse this quiz to self-check your understanding of the module content. You can also go online and take thisquiz within the module. The online quiz provides the correct answer once submitted.1. Which of the following is a possible root cause contributing to an accident?a. The wrong toolb. A defective machinec. No safe work procedured. A person2. Which of the following is a surface cause for an accident?a. An inadequate policyb. A personc. No written pland. Unsafe process3. Surface causes describe hazardous _________ and unsafe _________. Root causes describe inadequate________.a. Systems, behaviors, conditionsb. Behaviors, activities, policiesc. Conditions, behaviors, systemsd. Conditions, systems, accountability4. The ___________ of the injury depends on the __________ of the transfer of harmful energy.a. magnitude, probabilityb. probability, magnitudec. magnitude, severityd. severity, magnitude
  54. 54. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 54 of 715. Which of the following would be the form of hazardous energy transferred if an employee were to fallto a lower surface?a. kineticb. thermalc. chemicald. acousticGo online and submit your quiz to receive the correct “book” answers.
  55. 55. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 55 of 71Module 7: Developing SolutionsWhat is a good recommendation?An accident investigation is generally thought to be a "reactive" safety process because it is initiated onlyafter an accident has occurred. However, if we propose recommendations that include effective immediatecorrective actions and system improvements, we may transform the investigation into a valuable "proactive"process that helps to prevent future injuries. In this module well explore tips and tactics for making effectiverecommendations that "sell" safety improvements.Once you have developed engineering and administrative controls to eliminate or reduce injuries, thechallenge becomes convincing management to make changes. Management will most likely understand theimportance of taking corrective action and readily agree to your ideas. However, if management doesntquite understand the benefits, success becomes less likely. Your ability to present effectiverecommendations becomes all that more important. This module will help you learn how to put together "anoffer they cant refuse," by emphasizing the long-term bottom-line benefits of the corrective action you arerecommending.Why decision-makers dont respond quicklyWhen recommendations are not acted upon, it is usually because the decision-maker does not have enoughinformation to make a judgment. To speed up the process and to improve the approval rate, you must learnto anticipate the questions the decision-maker will ask in order to sign off on the requested change. Thisbeing the case, the more pertinent the information included in the presentation, the higher the odds are forapproval.Do it right!Its important to divide your recommendations into the categories below. Immediate or short-term corrective actions to eliminate or reduce the hazardous conditions and/orunsafe behaviors related to the accident.
  56. 56. OSHAcademy Course 702 Study GuideCopyright © 2000-2013 Geigle Safety Group, Inc. Page 56 of 71 Long-term system improvements to create or revise existing safety policies, programs plans,processes, procedures and practices identified as missing or inadequate in the investigation.Some employers may assign the responsibility for making recommendations to safety directors or othermanagers. However, you, as the accident investigator, may be required to take on this very importantresponsibility. Consequently, its a good idea to know where to start, and how to write strongrecommendations. One tip up front: If you find the responsibility is yours, be sure to get the help of experts ifyou are unsure how to proceed. OSHA consultants, other safety professionals or your workers compensationinsurer can be a great source for help.The Hierarchy of Control StrategiesLets discuss the six hazard control strategies that Ive grouped into the two categories described in module7.2. As a safety professional, you need to be familiar with these basic strategies. You can be sure theyll be onthe exam :-)Higher priority strategies that control hazards1. Elimination. Totally eliminate the hazard. (no hazard - no accident) Why is this control strategy ourtop priority? Employing an engineering control has the potential to completely remove the hazard.Were somehow changing a thing/condition in the workplace. And as we all know...No hazard, no exposure = no accident.2. Substitution. Substitute the hazard with a less hazardous condition, process or method. Some basicexamples are, substituting a toxic chemical with a non-toxic chemical, or replacing an old poorly-designed machine with a new model.3. Engineering controls. See if any of the strategies below are used in your workplace. Design. Example - Design a tool so that it reduces the likelihood of an strain or sprain. Redesign. Example - Change the design of a machine so that dangerous moving parts orelectrical circuits are out of reach.• Enclosure. Examples - Place a hood over a noisy printer. Place a machine guard around a

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